2015_0825 CITY OF COPPELL WATER UTILITIES
� CUSTOMER SERVICE INSPECTION
Residential Commercial ❑ TNRCC ID t�0570040
I U�- �' �� �� ,upon inspection of the pnvate water disri-ibution facilities located at
�f�� ` �c��if� � �r , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Comp�l�i '�`e Compliance
(1) No d'uect connection between the public drinking water supply and a potential Q ❑ ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking water supply and a private water � p ❑
system exists. Where an actual air gap is not mainfained between the public water
supply and private water supply, an approved reduced pressure-zone backflow
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing fB� ❑ p
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water p' ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ❑
dis�-ibution facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution faciliries unril the above conditions are deternuned to be
in compliance.
I certify that the following materials will be used in the installation of the private water disuibution facilities located at �1 y _
5 G p�Di,O�LL and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other ❑_/�
Solder Lead ❑ Lead Free C9� Solvent Weld ❑ Other C'l
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res nsible for the validity of the information I have provided.
/��, �;� 7 �
gnature of Licensed Plumber Registration Number
� 1'J'f � -- ��zs�i��
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
�- �� � �
nature of Inspector Registration Number
�l�� !� 1��'S ►"S �'�d�� �/�'�—
Type of Registration Date
White-Customers Copy Yellow-City's Copy Pinlc-faspeaors Copy